If you are a human and are seeing this field, please leave it blank.

First Name

Last Name

Date of Birth

Height

Weight

Please describe your sleep concerns in the space below including when it started.

Have you previously been evaluated in a sleep facility or treated for any sleep problems?

If Yes, then which facility? What was the Date of the Test? And the Results of the test?

List any present health problems and treatments

Work day/Weekday

Bedtime?

Awakening Time?

How long do you think it takes you to fall asleep?

How many times do you wake up on an average night?

What wakes you up?

How long are you awake during these awakenings?

How much total sleep do you get these nights?

Day off/Weekend

Bedtime?

Awakening Time

How long do you think it takes you to fall asleep?

How many times do you wake up on an average night?

What wakes you up?

How long are you awake during these awakenings?

How much total sleep do you get these nights?

Do you believe you have insomnia?

Yes

No

In what position do you sleep?

Front

Back

Side

Flat

Head Elevated

Do you use oxygen at home?

Yes

No

If Yes, How much?

Do you wake up short of breath?

Yes

No

If Yes, Describe

Do you wake up gasping or choking?

Yes

No

If Yes, Describe

Do you wake up with a headache?

Yes

No

If Yes, how often?

Do you snore?

Yes

No

If Yes, how much?

Have you been told that you stop breathing in your sleep?

Yes

No

If Yes, how often?

Do you have a restless or uncomfortable feeling in your legs when lying down?

Yes

No

If yes, does this feeling contribute to insomnia?

If yes, how often?

Do you kick in your sleep?

Yes

No

If yes, how much?

How many cups of regular coffee (not decaf) do you drink per day?

How many glasses of tea (not decaf) do you drink per day?

How much soda (not decaf) do you drink per day?

How much chocolate do you consume each day?

How much alcohol do you drink?

Do you smoke or use nicotine containing products?

Yes

No

If Yes, how much per day?

Do you take medications to help you sleep (prescription or over-the-counter)?

Yes

No

If yes, give name and dose

If yes, In a week how often do you take it?

Do you take medications to help you stay awake?

Yes

No

If yes, give name and dose:

During the day, do you feel

Sleepy

Fatigued

Tired

Have you ever fallen asleep eating, talking or driving?

Yes

No

If yes, how often?

If yes, explain?

How many times per week do you take a nap on purpose?

How long do you sleep for?

How do you feel upon awakening?

How many times per week do you fall asleep in quiet situations (TV, reading, etc.)?

How long do you sleep for?

How do you feel upon awakening?

Do you have vivid dreams within a few minutes of falling asleep?

If yes, how often?

Have you ever woken up with your whole body temporarily paralyzed?

Yes

No

If yes, how often?

Have you ever had sudden weakness/loss of strength, particularly after anger or laughter?

Yes

No

If yes, how often?

If yes, explain

Do you have any unusual behaviors while sleeping?

Yes

No

If yes, explain

Do you have high blood pressure?

Yes

No

Are you being treated for high blood pressure?

Yes

No

Have you ever had a stroke?

Yes

No

Have you ever had memory loss?

Yes

No

Have you ever had a heart attack?

Yes

No

Do you have Coronary Artery Disease?

Yes

No

Do you have depression?

Yes

No

Do you have mood swings or bipolar disorder?

Yes

No

Please describe any additional information that you feel is relevant to your sleep.

EPWORTH SLEEPINESS SCALE

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.